Methodological reflection about the fieldwork of an international multisite research Brazil-Canada

Zanchetta, Margareth Santos; Santos, Walterlânia Silva; Souza, Kleyde Ventura de; Viduedo, Alecssandra de Fátima Silva; Argumedo-Stenner, Hannah; Carrie, Dakota; Aviv, Francesca; Hwu, Hilary; Stahl, Hannah; Fofie, Vanessa; d’Souza, Dorin; Oliva, Milena; Tadeo, John; Costa, Edwaldo; Vilela, Francisco; Carvalho, Andréa; Escobar, Haydée Padilla Vda de; Felipe, Ingryd Cunha Ventura

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REFLECTION • Esc. Anna. Nery 25 (2) • 2021 • https://doi.org/10.1590/2177-9465-EAN-2020-0390 copy

Methodological reflection about the fieldwork of an international multisite research Brazil-Canada

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Aim

To present the results of a structured reflection on the methodological phases of an international research in Brazil regarding the implementation of the Program of Humanization of Prenatal and Childbirth, as well as, reflection on the project's social actors.

Method

A reflective research method that modifies the perception of a given situation, leading to new ideas, revealing themes of analysis, and engendering proposals for possible solutions with the creation of an action plan. The object of the reflection was the participation of co-investigators in an international, multidisciplinary, and multisite ethnographic study, implemented in June/2019-March/2020.

Results

The reflections indicate emotional sensitivity to the theme and silence about obstetric violence. There are multiple manifestations of institutionalized violence including resistance to confronting obstetric violence in hospital settings, negligence and distorted questioning in the political spaces of organizational authorization. The delay caused by a research ethics committee put the timetable for completion of research development at risk by requiring funding from a foreign agency.

Conclusion and implication for practice

Structured reflection allowed a unique learning process for co-investigators navigating different university and social research cultures.

Keywords:
Global Health; Nursing Methodology Research; Qualitative Research; Violence Against Women; Women’s Rights

Reflections

This perspective (of the humanization of labour and childbirth) has been strengthening based on experiences of training generalist nurses and specialists in this field. For that reason producing knowledge through it and by the experiences we have lived as representatives of a professional nursing association, but fundamentally for the fact of being in this field for over 30 years, and hopefully – hope…here placed as historical concreteness, as becoming of bodies immersed in a scientific, ethical-political practice -social and humanist, as is Nursing. To join in a solidarity and collective action as it is established in the production of this research. Hence, the whole sense of forming this collective of researchers and Brazilian public organizations, in an international partnership, in which collective health and humanization in health, in the specific field of obstetric and neonatal care, can be enhanced. This was the path we took to understand that together, in / for carrying out this research, it will be possible to apprehend an object of study that constrains us all - Obstetric Violence - seeking to unfold it in its challenges: violence / institutional racism, childbirth violence, gender violence, health inequalities, among others, but which does not immobilize / will immobilize us. It is, therefore, an object that we must understand as a starting point. (Brazilian co-principal investigator in Brazil, 33 years of experience as an obstetric nurse, Belo Horizonte-Brazil)

In a Brazilian context of restricted funding for nursing research and the widespread interest in implementing internationalization projects, the status of 17 university nursing faculty with recognized clinical knowledge did not guarantee the expected respect when negotiating the processes of organizational authorization. Despite the extremely serious and formal process that I implemented following Canadian guidelines for international scientific cooperation, I was surprised to see the numerous attempts to interfere in the content of the research project, questioning the methodological rigor and the total disregard for the timeline for implementation/conclusion. Such non-compliance can make foreign-funded research unfeasible due to strict schedules. (Brazilian-Canadian researcher, principal investigator, 40 years of experience, Toronto-Canada)

Reflections
From the experience with the participants, I was able to perceive the subtleness of their actions; for example, when the pregnant woman perceives herself to be vulnerable, this state corroborates the permissiveness of some acts, and, after that, they may have a different understanding for the same situation. So, it is not restricted to procedures without consent, since in many cases, women agreed with oxytocin; to be quiet in bed; in long wait times, instead of scheduling; to agree with the structure of the place where they were served, even though they perceived aspects to improve, seen by themselves as too demanding and, thus, to be content to be served, only. This issue is not limited to the dissemination of health information. Therefore, the challenge of implementing the prenatal and childbirth humanization program includes effectiveness in the care process, in the collective sense, and overcoming the only transfer of information about rights to women, as well as of the child and family, but informing that people deserve better quality care. To this end, the awareness of health, education, work, science, technology and communications constitute a basis for government action so that it can equip people in general, because if women do not claim, no matter how well educated in health they feel, others do. And, when talking to women about obstetric violence, I also had the opportunity to self-reflect on my professional condition. (Brazilian co-investigator, 20 years of experience in Public Health, Brasília-Brazil)
The involvement in [social media] was very different, it was very profitable, since all the work had to be done together with the international responsible, our media staff, so that the content was suitable for the target audience. And we were able to see this on social networks, we were able to reach this focus, which had a lot of participation from women, we were successful on the response with [social media]. The CHAs felt important, they also suffered ... because there was [x number] that ended up participating, as long as their reports. They saw the importance of their participation in this project, they saw themselves there, it was a moment when they could show the greatness of their work, they could understand the greatness of they work. (CHA, collaborator in announcement and recruitment, 18 years of experience, São Gonçalo-Brazil)
I was very happy to know that these interns are developing methodologies, they are thinking about broader health for everyone, because they are interns everywhere. It was very important, as an observer and participant in the meetings, to observe that the health area is increasingly reinventing itself, increasingly wanting to improve…, trying to see the rights of all women, pregnant women and why not their future babies who can come to have this knowledge, so that obstetric violence does not perpetuate, that other professionals are educated..., with that they retain the knowledge and this issue of obstetric violence ends once and for all. This is the crucial point of knowledge, this is the most sensible point of health education so that future mothers will no longer experience any problem of obstetric violence. This is the point that I was most pleased to be part of this whole project, to know that there are people, there are professionals who want to change this concept, they want to change this health failure, which is obstetric violence. (CHA, recruitment collaborator, 18 years of experience, São Gonçalo-Brazil)

Reflections
Often, during data collection, the question arose as to whether women are aware or not of having suffered violence. This raises the question of what defines violence and what defines a victim. Many women who experience obstetric violence do not see themselves as being abused. The story of what happened to them can be portrayed in different ways, and we can be the first to attribute the word “victim” to them. Even so, all of these women are survivors of this violation of their fundamental human rights. Violations of these rights, promulgated through physical, emotional, spiritual and economic forms of violence, trying to keep women “in their place”. They do not make room for the woman who speaks, who is loud and not afraid to show pain, or the woman ... who may be having a child without the conventional family structure. Instead, they want only submissive and obedient women. However, even many of the women who are afraid to keep quiet, who act “perfectly”, are unable to escape the threat of violence during the vulnerable moments of childbirth. (Social work undergraduate student, Niterói-Brazil)
My experience collecting data in qualitative research on violence against women has made me aware of my limited ability to help women who have shared their moral, psychological and spiritual pains. In a focus group with women who are CHAs (rural area, Rio de Janeiro) in this research, two of them did not report experiences of their clients; in an explosion of catharsis they revealed personal experiences with obstetric violence. The first reported, as a parturient, the physical violence suffered, in tears, under the astonished gaze and the respectful posture of the other community health agents (and my silent prayers that God would help us to act with solidarity in careful silence). The second, as the mother of an adolescent parturient, reported while crying, a shocking interaction with the nursing team composed of indifferent women who promoted institutional violence. This mother's requests for her to remain with her daughter, terrified by the risky delivery situation, were ignored. Except for one of the non-professional women who pledged to “look more” for the teenager in labor. It is revolting to see how women in nursing also perpetuate this monstrosity in organizational settings. (Brazilian-Canadian researcher, principal investigator, 40 years of experience, Toronto-Canada).
I had the opportunity to hear a report from a 45-year-old immigrant postpartum woman. A year after her birth she was still in pain because her rights had been violated. According to her, she had no comorbidities during pregnancy, had a doula and followed prenatal care expecting a normal delivery. Because she is an immigrant, in her culture she doesn't even think about opting for a cesarean delivery, however, the day she went into labor she went to the hospital, called the doctor who accompanied her, her parents who were in Brazil and her husband, all ready for the baby's arrival and here's the surprise, her doctor informed her that due to her age, a cesarean delivery would be better. She reported that the environment was claustrophobic, that she was not given any comfort, with the opinions all contrary to the birth plan she had made, she was also afraid of what would happen to her son if she did not accept the advice that led her to cesarean delivery. One year after childbirth she is still processing the invisibility of the violence she suffered, something she was unable to do on the day of childbirth due to the invisible pressures she suffered. (Brazilian co-investigator, 24 years of experience in Obstetric Nursing, Brasília-Brazil)

Reflections
As a researcher involved in the design of the project and in the transcription of 26 hours of audios related to the interviews and focus groups, the women's narratives about the suffered obstetric violence called my attention, revealing the inappropriate professional conduct in the care of the women and the newborn. It seemed intriguing to me that many women do not have information about their rights, as well as feel frightened by the professional confrontation and its consequences. However, others exposed extremely positive experiences when reporting the welcoming, safe and quality care received from the multidisciplinary team. I think that information is the key to expanding quality service, both for women and health professionals. (Brazilian co-investigator, 13 years of professional experience, Toronto-Canada)
I conducted about 20 interviews to produce a documentary about the research. In the statements of the coordinators/researchers, the importance of the exchange of knowledge between Brazilians and Canadian researchers was perceived in order to inform women about obstetric violence and make them aware of their rights. In the speeches of community health agents and nurses, the relevance is in the way the project was carried out, mainly in the practical part. With students discussing the subjects with professionals and patients within Primary Health Units, communities and/or hospitals, they said that the impact of the research was positive and that, in a way, they managed to “translate” what is obstetric violence for many women, community members and even professionals. It was exciting to record with the students. For most nursing students, the project allowed for the first time to watch a childbirth. Some mentioned that it was the most beautiful thing they have ever witnessed and were sure of the real importance of the profession, regardless of the country or culture. The social work students confessed that it was in Brazil, during the internship, that they realized the vast field of work that health makes possible for them. One said that she already decided to pursue hospital care because she wants to guarantee people’s rights and access to public policies. (Brazilian co-investigator, 15 years of professional experience, Brasília-Brazil)
I observed with the meetings with academics and teachers ... how much interest there is in addressing this issue, how broad this subject is, how much there is to address, how many answers must still have been hanging in the heads of these mothers. The idea that came up there to make educational videos with obstetric nurses training community health workers for this approach is very interesting. As a professional who does not have all this expertise, I am satisfied to participate in this project and bring knowledge to these mothers who need more knowledge, more instructions, more about their rights, not to suffer obstetric violence, not to pass because of this constraint and not knowing how to defend themselves in such a way, because they have no knowledge, they do not know that the health professional who is attending is wrong. Knowledge for them is essential and, in these videos that will be covered, they will be short, they will be in simple language, didactic, they will have the most professional part of the specialized nurse, but they will also have the community agent speaking on a daily basis, in a simpler language. (CHA, collaborator in planning the dissemination of results, 18 years of experience, São Gonçalo-Brazil).
It was excellence in our work. The CHAs felt not only important, but some who participated as a target audience saw the importance of the work that was done, it was exciting, they comment on this work, their involvement there, they wait for the return, the response of this project, to see what was done, what was the result of this work, they are waiting for it, as I am also waiting for. (CHA, recruiting collaborator, 18 years of experience, São Gonçalo-Brazil)

Areas of possible actions
In the administrative scope of the universities:
- Articulate dialogue between local, national and international ethics committees on their modus operandi with a priority focus on protecting participants.
- Mobilize the international affairs office to ensure the formal presentation of international co-investigators to local collaborating organizations.
- Increase the engagement of the vice-provost of research from the universities hosting the projects to make ethics committee procedures complete in a timely manner, respecting the work schedule by international funding agencies.
At the State / District / Municipal administrative level regarding data collection sites:
- Present the research project using an audiovisual approach to the clinical staff and organization administration to expand their understanding about the research.
- Promote organizational dialogue on the social value of the proposed research.
Within the scope of civil society:
- Establish formal recruitment partnerships with professional and community associations.
- Expand advertising about research in all site of data collection using all social media.
Within the research team:
- Add undergraduate students as co-investigators in training with similar duties, rights and responsibilities with other team members.
- Develop promotional material about the research, considering different target audiences and prioritizing audiovisual material.
- Harmonize pre-existing working methods and communication strategies in research sub-teams from different countries.
- Mobilize the potential of local and foreign undergraduate and graduate students by connecting them to the research programs of their mentor-researchers.
- Train students as research assistants with the use of realistic simulation, to enter the field of local research paying attention to differences related to the context of life and academic origin.
Within the scope of data collection
- Ensure that data collection under a sensitive theme is conducted by researchers able to respond to the participants' destabilizing emotional situations.

Universidade Federal do Rio de Janeiro Rua Afonso Cavalcanti, 275, Cidade Nova, 20211-110 - Rio de Janeiro - RJ - Brasil, Tel: +55 21 3398-0952 e 3398-0941 - Rio de Janeiro - RJ - Brazil
E-mail: annaneryrevista@gmail.com

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[1] Corresponding author:
Margareth Santos Zanchetta. E-mail: mzanchet@ryerson.ca.